DEFINITION OF FRACTURE:

A break in normal continuity of bone with or without loss of bony contour when stretched or bent beyond its elastic limit due to any trauma or any pathology is referred to as fracture. This breaks in normal continuity results imbalance of bony architecture, muscular pull and overlying soft tissue. This is turn result in loss of function.

INTRODUCTION OF MANDIBULAR FRACTURE:

As the mandible is a hoop of bone articulating with the skull at its proximal ends by two joints and since the chin is a prominent feature of face, the mandible is prone to fracture. The mandible has been compared to an archery bow, which is the strongest at its center and weakest at its end, where it breaks often. Hence, the fracture occurring in any part of mandible refers to as mandibular fracture.

• INCIDENCE:
Mandibular fracture is more common than middle third injury. The most common facial fractures areMandible Maxilla Zygoma Nasal bone : : : : 61% 46% 27% 19.5%

• AETIOLOGY:
The causes of fracture are – • Traumatic:  Road traffic accident-Major cause  Fall  Assault
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    

Sports injury, gun shot injury, industrial injury War Violence Blow Faulty tooth extraction

Pathological:  Osteolytic lesion Osteo fibroma  Fibrous Dysplasia  Atrophic bony condition Paget’s diseases  Other pathologies Osteomyelitis  Osteoporosis  Osteogenic imperfecta  Osteonecrosis  Large cyst

MANDIBULAR AREAS OF WEAKNESS: unerrupted 3rd molar Neck of the condyle Symphysis & parasymphysis of the mandible Angle of the mandible Presence of foramina a) Mental foramina b) Inferior dental foramina Mandibular notch

1. Presence of tooth/teeth bearing area-longest root of canine, impected or

2. 3. 4. 5. 6.

• CLASSIFICATION: The classification of mandibular fracture based on the following criteria: A. Based on anatomical location-

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1. Angle of the mandible-31% of all mandibular fracture 2. Body of the mandible-36%

Molar region -----------15%  Mental region-----------14%  Cuspid area--------------7% 3. Condylar process—About 18% of all mandibular fracture 4. Symphysis and parasymphysis ---8% 5. Ramus of the mandible—6% 6. Coronoid process—1% 7. Dento-alveolar region

Fig: Sites of fracture B. Based on the types of fracture: 3. Simple Fracture: When there is a break in continuity of bone without break in mucosa or skin that is the fracture fragments not exposed to the external environment.

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Fig: Simple fracture 2. Compound Fracture: When the fracture ends of the bone are associate with the break in continuity of skin or mucous membrane there by communicating with external environment

Fig: Compound fracture 3. Communited fracture: When the fractured fragments are more than two Simple communited fracture- when there is no external communication  Compound communited fracture-when there is external communication

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Fig: Communited fracture 4. Greenstick Fracture: It occurs mainly in children. The bone in the children is soft and elastic so a crack in the bone in which one cortex of the bone is fractured where as other cortex is bent only as in case of green stick of a tree.

Fig: Greenstick fracture 5. Pathological Fracture: The fracture occurs from mild injury or as a result of normal degree of muscular contraction due to weakness caused by pre-existing bone pathology.

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Fig: Pathological fracture

C. Based on the causes of the Fracture: 1. Direct fracture: If fracture occurs at the site of impact, it is referred to as direct Fracture 2. Indirect Fracture: If the fracture occurs away from the site of impact, it is referred to as indirect fracture. 3. Excessive muscular contraction: Sudden musculature contracture may also causes some fracture such as fracture of the Coronoid process because of the sudden reflex contracture of the Temporalis muscles & also fracture of the Condylar neck.

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Fig: Direct and indirect fracture D. Based an the direction of the fracture and favourability for treatment:
1. Favorable fracture:

A fracture is said to be favorable if the muscular pull resists the displacement of the fracture— a. Horizontally favorable fracture b. Vertically favorable fracture

A

B

Fig: A) Horizontally favorable fracture B) Vertically favorable fracture
2. Unfavorable Fracture:

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A fracture is said to be unfavorable if the muscular pull does not resists the displacement of the fracture— a. Horizontally unfavorable Fracture b. Vertically unfavorable Fracture

A

B

Fig: A) Horizontally unfavorable fracture B) Vertically unfavorable fracture E. Based on treatment points:
1. Unilateral Fracture:

o Unilateral Fracture of the body of the mandible 2. o o o Bilateral fracture: Angle of the mandible Canine region Condylar neck

3. Multiple Fracture The most common multiple fracture is caused by a fall on the mid point of the chin resulting in fracture of the Symphysis & both condyles. It is usually seen in epileptics, elderly patients and occasionally in soldiers. So it is called –Guardsman fracture.
4. Comminuted fracture:

o Symphysis & parasymphyseal region (most common) o War missiles injuries

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F. Based on the presence or absence of teeth:
1. Class –I: When teeth are present on both side of the fractured line. 2. Class-II: When teeth are present on one side of the fractured line. 3. Class-III: When both the fragments of each side of the fractured line are

edentulous.

A

B

C

Fig: A) Class-I B) Class-II C) Class-III • ROLES OF MUSCLE DISPLACEMENT OF FRACTURE: 1. Muscles of facial expression:

MANDIBULAR

They do not play any important role in the displacement of fracture of mandible, as the origin of these muscles from bone & insertion into the skin. To displace the bone the muscle should originate and insert into the bone only. 2. Muscle of mastication: o Masseter, Medial pterygoid, Temporalis and Lateral pterygoid muscle help in opening and closing of the jaw. These muscles displace angle and condyle of the mandible o Masseter, Medial pterygoid, Temporalis muscles displace fractured ramus upward and medially

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o Lateral pterygoid muscle helps in displace the neck of condyle anteriomedially. 3. Accessory muscles of mastication: o Mylohyoid, Geniohyoid, Digastric & Genioglossus muscles pull the body of the mandible downward and medially. o Mylohyoid, Geniohyoid, Digastric & Genioglossus muscles pull the Symphysis downward and backward.

Fig: Diagram showing muscular pull in mandible; A) lateral view B) medial side C) Horizontal views

• SIGN AND SYMPTOMS OF MANDIBULAR FRACTURE: History of injury. Acute continuous pain with swelling of lower part of face. Discoloration of skin. Soft tissue laceration. Bleeding from the mouth. Break in the continuity of bone with the deformity of the facial symmetry.  Break in the continuity of mucosa with swelling in the floor of the mouth.      

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 Break in the continuity of dental arch and loss mastication with abnormal mobility.  Difficulty in chewing and swallowing.  Inability to open the mouth and difficulty in closing of mouth leading to loss of function.  Foul odour and excessive salivation as the patient can not clean the oral cavity.  Abnormal occlusion.  Anterior open bite and lateral cross bite.  Deviation of mandible during movement mainly seen in the unilateral fracture.  On palpation-a crepitus sound may be felt.  A step deformity may be in the lower border of the mandible, occlusal surface and upper border of the mandible.  Trismus mainly in the fracture of ramus  Neurological defect.

• MANAGEMENT OF FRACTURE OF THE MANDIBLE: 1. Immediate or emergency treatment: A. Airway maintenance: 1. Clear the mouth and throat of blood clot, tenacious salivary secretion, and foreign bodies like denture or luxated tooth with the help to powerful suction and wet swab.
2. As there may be a back fall to tongue due to unfavorable bilateral

parasymphyseal Fracture; so pulling the tongue forward should treat it and

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passing a stay suture through the tongue that can be stabilizing with the shire of the patient. 3. Patient should be placed in the position similar to the recovery from GA or sitting up with head held forward with adequate support. 4. Continuous supervision of patient. 5. Airway tube. 6. Cricothyroidotomy 7. Tracheostomy B. Bleeding control:
1. Pressure and pack is the best method to control haemorrhage.

2. Arterial haemorrhage should be controlled with digital pressure on the pressure point. Clamp the artery with forceps & ligate it. 3. Packing with gauge can control haemorrhage from the deep wounds till other measure can be taken. C. Control of circulation: Control of haemorrhage or neurogenic shock. 2. Diagnosis and evaluation of patient: A. History Taking: 1. Accurate detail and proper history of patient should be taken as per clinical or medico logical point of view. 2. If the patient is unable to give statement then the same should be recorded from accompanying person, relative, friends or police officers. 3. It will reveal about how the injury occured, the type of injury & the severity of the injury. B. General examination:

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1. It should be carried out to look for any serious injury elsewhere in the body

so that the appropriate specialist could be consulted. 2. Inspection & palpation of head for any soft tissue as well as bone injury. 3. Inspection & palpation of chest & abdomen for any injury. C. Regional examination: 1. Extra oral: -Inspection -Palpation
2. Intra oral:

- Inspection - Palpation D. Radiological examination: I. Extra-oral radiograph: a. P/A view of mandible in open mouth. b. Right and left lateral oblique view. c. X-ray for TMJ in both opened and closed mouth position. 4. OPG. II. Intra-oral radiograph: a. Periapical view. b. Occlusal view.

Fig: OPG shows fracture of the body of the mandible and right condylar region 3. Definitive treatment:
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1. Conservative treatment: When fracture line seen but no displacement then conservative treatment is donea) Control of painA patient of fracture of mandible experiences extreme degree of pain and may go into shock because of severe pain so IV-Diazepam can be given in the dose of 10 mg combined with 20 mg Pentazocine as analgesic. b) Control of InfectionPrevention of infection in case of fracture or control of already established infection is of outmost importance so, Antibiotic should prescribe c) Temporary stabilization of fractured part: Temporary stabilization of splinting of the fractured fragments with the help of barrel bandage. Temporary stabilization in the form of horizontal wiring is also a effective procedure. d) e) f) g) Soft diets Oral Hygiene instruction Advice to the patient to shouldn’t move the jaw vigorously Follow-up.

2. Active treatment: If displacement occurs then active treatment is done. The treatment follows some principles.

PRINCIPLES OF TREATMENT OF FRACTURE: A) Reduction: It is the process of bringing the fractured fragments into alignment.

Types of reduction: 1). Closed Reduction:
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It is usually done in simple fracturea) Whenever closed reduction is possible the risk of subsequent infection of the fracture is negligible. b) Precise anatomical reduction is not necessary in fracture of denture bearing area. c) Pulls or manipulate the bone under the intact skin to fracture in proper position.

A A B

Fig: A) Closed reduction B) Extra-oral open reduction 2. Open Reduction: a) If widely displacement occurs the open reduction must be anatomically precise when teeth are involved which were previously in good occlusion. b) Open reduction and immobilization is best effected under General Anesthesia- when severe compound fracture. c) Sometimes open reduction done under local anesthesia- when fracture is not so severe. B) Fixation: It is a procedure by which the fractured bone ends are fixed in reduced Position. Types: a) Direct fixation (ex-mini plate, bone plate) b) Indirect fixation (ex- arch wiring)

C) Immobilization:

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The reduced and fixed fragments of the bone are immobilized for certain period for healing. Healing of fracture: • Clotting of blood • Organization of haematoma • Formation of fibrous callus • Formation of primary callus o Uniting callus o Bridging callus o Anchoring callus o Sealing callus D) Rehabilitation Return to normal function and appearance is the goal of all clinical examination. • TIMES OF IMMOBILIZATION OF FRACTURED MANDIBLE: Period of immobilization depends upon the site of fracture, presence or retained teeth in fracture line, age of patient and presence or absence of infection. A simple guide to the time of immobilization for the fracture of tooth bearing area of the lower jaw is as follows. Young adult with fracture of the angle receiving early treatment in which tooth removed from fracture line – 3 weeks If: 1. 2. 3. 4. If tooth retained in the fracture line, add 1 week Fracture in the Symphysis, add 1 week Age 40 years or over, add 1 to 2 weeks Children or adolescents, subtract 1 week.

Applying this guideline is follows that a fracture of the Symphysis in 40 years old patient when the tooth in the fracture line is retained requires 6 weeks immobilization. (Basic 3 weeks +1 week for less favorable site+ 1 week allowed for age+1 week for tooth retained in the fractured line)

METHODS OF IMMOBILIZATION:
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A) Intermaxillary fixation: 1. Dental wiring:  Direct wiring or glimmers direct method of wiring  Eyelet wiring or Ivy Eyelet wiring or Interdental wiring. 2. Arch bar wiring: 2. Splints: Cast metal splint, acrylic cap splint and gunning splint.

Fig: Arch-wiring

Fig: Intermaxillary fixation

B) Intermaxillary fixation with osteosynthesis: 1. Direct intra-osseous wiring/ trans-osseous wiring  Upper border intra-osseous wiring  Lower border intra-osseous wiring  Figure ‘8’ wiring  Four hole system  Two hole system 2. Trans fixation with Krischner’s wiring 3. Circumferential wiring. 4. External pin fixation 5. Bone clamps 6. Implants/ Grafts

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Figure ‘8’ wiring

Two hole and four hole system

Fig: Intraosseous or transosseous wiring C) Osteosynthesis without Intermaxillary fixation: 1. Simple or non compression bone plate 2. Compression bone plate 3. Mini plate.
A B

Fig: After reduction fixation with A) mini bone plate B) compression bone plate • EDENTULOUS JAW FRACTURE: Methods of immobilization: 1. Intermaxillary fixation using gunning type of splints  Used alone  Combine with other method 2. Direct skeletal fixation  Trans osseous wiring
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 Bone plate  Trans fixation with Krischner’s wire- when body of the mandible is less than 10 mm in depth  Cortico-cancellous bone grafting. 3. Indirect skeletal fixation  External pin fixation  Bone clamps

Fig: Edentulous fracture • POSTOPERATIVE CARE: 1. Immediate Postoperative Care: When the patient is recovering from the general anesthesia:  Instrument of fixation and instruments such as, scissors, wire cutter, screwdrivers etc. should be available so that the fixation can be removed emergency.  Control of tongue in unconscious patient to additional safeguard, a tongue suture passed transversely across the dorsum of the tongue.  An efficient suction apparatus should be at the patient’s bedside. 2. Intermediate post operative care: General supervision:  Correction of unacceptable reduction  Occlusion should be checked as early as possible  Inspection of fixation

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 Should lie on the lateral posture  Sedation: With Diazepam (Dose is adjusted according to the patient’s response to 5 mg increment)  Prevention of infection- with prophylactic antibiotic.  Oral Hygiene: Mouthwash with 0.2% chlorohexidine gluconate. The lips tends to stick together so the lips and mouth should be cleaned with moist saline swabs at regular intervals and the lips regularly lubricated with steroid containing ointment or petroleum jelly.  Feeding- Liquid/soft diet/ (2000-2500) cal/day. - Fluid balance by daily intake about 3 L water. 3. Late post operative care: Testing of the union and removal of fixation. Adjustment of occlusion Mobilization of TMJ Micro neural repair of both inferior dental nerve & lingual nerve may be needed.  Oral Hygiene, specific periodontal treatment, removal of prosthesis may be part of care.     • COMPLICATIONS:  Infections: 1. Abscess resulting in necrosis and Osteomyelitis 2. Fracture with chronic facial fistula due to chronic infection Neurological defect: It occurs in damage of inferior dental nerve. Displaced tooth and foreign bodies. Misapplied fixation Pulpitis- Damaged tooth may develop pulpitis or apical infection during period of fixation.  Gingival and periodontal complications: -Local gingivitis may occur. If too much interdental force to individual tooth is applied then periodontal problem may develop.  Malnutrition  Non-union, Delayed union, Mal-union, Fibrous union    
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      

Ankylosis of temporomandibular Joint Sequestration of bone Incomplete closure of mouth due to fracture of Coronoid. Facial asymmetry and step defect Premature contact of tooth. Disturbance in occlusion Scars.

Fig: 1) Non-union 2) Bone grafting and fixation

• CONDYLAR FRACTURE: • CLASSIFICATION: 1. Extra-capsular fracture  Unilateral  Bilateral
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2. Intra capsular Fracture:  Unilateral  Bilateral 3. According to displacement:  No displacement  Forward displacement  Medial displacement  Lateral displacement

Fig: A) No displacement B) Forward displacement C) Medial displacement D) Lateral displacement • PRINCIPLES OF TREATMENT OF CONDYLAR FRACTURE: A) In case of children:  Intra capsular Fracture treatment: a) Active movement b) No immobilization c) No IMF d) Symptomatic treatment e) Analgesics f) Jaw movement  Extra-capsular fracture treatment: a) If displaced then IMF for 7-10 days followed by active treatment. b) If no displacement then no IMF.

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A

B

Fig: A) Reduction and fixation B) X-ray showing bilateral condylar fracture B) In Case of adult:  Intra capsular Fracture treatment: 1. Unilateral:  If occlusion is OK then IMF  If painful joint then IMF for 2 weeks 2. Bilateral:  Intermittent IMF  IMF for 2 weeks  IMF only at nights for 4 weeks  Extra-capsular Fracture treatment: 1. Unilateral:  IMF for 4 weeks  Open reduction if necessary 2. Bilateral:  IMF for 4-6 weeks  Open reduction if necessary 3. Both Unilateral and Bilateral:  Intermittent fixation.

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• POST OPERATIVE MANAGEMENT & INSTRUCTION: 1. To control of post operative pain: Analgesics for instance-Diclofenac Sodium (Tab. Inflame-200-400mg twice daily. After meal if necessary) 2. To control post operative infection-Antibiotic should given-Cap. Amoxicillin 500mg 8 hourly for 7-10 days. 3. As analgesics cause gastric irritation- an H2 blocker should prescribe. 4. Patient should strictly told not to move mandible vigorously 5. If IMF done than nasogastric feeding should be given 6. Soft diet 7. Regular follow up.

Based on Lectures of Asst. Professor Dr. Kazi Sazzad Hossain Department of Oral Surgery and Anaesthesiology

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BIBLIOGRAPHY:  Killey’s Fracture of the Mandible -by Peter Banks  Text book of Oral and Maxillofacial surgery - by Vinod Kapoor  Text book of Oral and Maxillofacial surgery - by Neelima Anil Malik.  Contemporary Oral and Maxillofacial surgery - by Peterson, Ellis, Hupp, Tucker.  Text book of Oral and Maxillofacial surgery –by Gustav O. Kruger

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